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Evaluation of GPT-4 ability to identify and generate patient instructions for actionable incidental radiology findings

Woo, Kar-Mun C; Simon, Gregory W; Akindutire, Olumide; Aphinyanaphongs, Yindalon; Austrian, Jonathan S; Kim, Jung G; Genes, Nicholas; Goldenring, Jacob A; Major, Vincent J; Pariente, Chloé S; Pineda, Edwin G; Kang, Stella K
OBJECTIVES/OBJECTIVE:To evaluate the proficiency of a HIPAA-compliant version of GPT-4 in identifying actionable, incidental findings from unstructured radiology reports of Emergency Department patients. To assess appropriateness of artificial intelligence (AI)-generated, patient-facing summaries of these findings. MATERIALS AND METHODS/METHODS:Radiology reports extracted from the electronic health record of a large academic medical center were manually reviewed to identify non-emergent, incidental findings with high likelihood of requiring follow-up, further sub-stratified as "definitely actionable" (DA) or "possibly actionable-clinical correlation" (PA-CC). Instruction prompts to GPT-4 were developed and iteratively optimized using a validation set of 50 reports. The optimized prompt was then applied to a test set of 430 unseen reports. GPT-4 performance was primarily graded on accuracy identifying either DA or PA-CC findings, then secondarily for DA findings alone. Outputs were reviewed for hallucinations. AI-generated patient-facing summaries were assessed for appropriateness via Likert scale. RESULTS:For the primary outcome (DA or PA-CC), GPT-4 achieved 99.3% recall, 73.6% precision, and 84.5% F-1. For the secondary outcome (DA only), GPT-4 demonstrated 95.2% recall, 77.3% precision, and 85.3% F-1. No findings were "hallucinated" outright. However, 2.8% of cases included generated text about recommendations that were inferred without specific reference. The majority of True Positive AI-generated summaries required no or minor revision. CONCLUSION/CONCLUSIONS:GPT-4 demonstrates proficiency in detecting actionable, incidental findings after refined instruction prompting. AI-generated patient instructions were most often appropriate, but rarely included inferred recommendations. While this technology shows promise to augment diagnostics, active clinician oversight via "human-in-the-loop" workflows remains critical for clinical implementation.
PMID: 38778578
ISSN: 1527-974x
CID: 5654832

Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission

Grabinski, Zoe; Woo, Kar-Mun; Akindutire, Olumide; Dahn, Cassidy; Nash, Lauren; Leybell, Inna; Wang, Yelan; Bayer, Danielle; Swartz, Jordan; Jamin, Catherine; Smith, Silas W
BACKGROUND:Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis. METHODS:The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests. RESULTS:The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education. CONCLUSION/CONCLUSIONS:The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
PMID: 38653614
ISSN: 1938-131x
CID: 5664452

A QUALITY INITIATIVE TO IMPROVE SEPSIS BUNDLE COMPLIANCE THROUGH UTILIZATION OF AN EHR TOOL [Meeting Abstract]

Warstadt, Nicholus; Mandola, Staci; Stark, Stephen; Toscano, Alessia; Creary, Kashif; Caldwell, Reed; Woo, Kar-mun; Jamin, Catherine; Dahn, Cassidy
ISI:000672597102361
ISSN: 0090-3493
CID: 5303842

Performance of Abbott ID NOW COVID-19 rapid nucleic acid amplification test in nasopharyngeal swabs transported in viral media and dry nasal swabs, in a New York City academic institution

Basu, Atreyee; Zinger, Tatyana; Inglima, Kenneth; Woo, Kar-Mun; Atie, Onome; Yurasits, Lauren; See, Benjamin; Aguero-Rosenfeld, Maria E
The recent emergence of the SARS-CoV-2 pandemic has posed formidable challenges for clinical laboratories seeking reliable laboratory diagnostic confirmation. The swift advance of the crisis in the United States has led to Emergency Use Authorization (EUA) facilitating the availability of molecular diagnostic assays without the more rigorous examination to which tests are normally subjected prior to FDA approval. Our laboratory currently uses two real time RT-PCR platforms, the Roche Cobas SARS-CoV2 and the Cepheid Xpert Xpress SARS-CoV-2. Both platforms demonstrate comparable performance; however, the run times for each assay are 3.5 hours and 45 minutes, respectively. In search for a platform with shorter turnaround time, we sought to evaluate the recently released Abbott ID NOW COVID-19 assay which is capable of producing positive results in as little as 5 minutes. We present here the results of comparisons between Abbott ID NOW COVID-19 and Cepheid Xpert Xpress SARS-CoV-2 using nasopharyngeal swabs transported in viral transport media and comparisons between Abbott ID NOW COVID-19 and Cepheid Xpert Xpress SARS-CoV-2 using nasopharyngeal swabs transported in viral transport media for Cepheid and dry nasal swabs for Abbott ID NOW. Regardless of method of collection and sample type, Abbott ID NOW COVID-19 had negative results in a third of the samples that tested positive by Cepheid Xpert Xpress when using nasopharyngeal swabs in viral transport media and 45% when using dry nasal swabs.
PMID: 32471894
ISSN: 1098-660x
CID: 4468402

Diagnosis And Management Of Deep Venous Thrombosis In The Emergency Department [Case Report]

Woo, Kar-Mun C; Goertz, Jacob K
Although the clinical presentations of deep venous thrombosis are notoriously subtle and nonspecific, risk stratification tools such as the Wells clinical model have improved the efficiency of the diagnostic evaluation. The emergency clinician may be guided down several pathways, including D-dimer assays and/ or ultrasonography. New oral anticoagulants offer alternatives to the traditional heparins and vitamin K antagonists in the treatment of deep venous thrombosis. This review examines the current literature, evidence, and guidelines in the diagnosis and management of deep venous thrombosis. It also explores some of the controversies and developments regarding risk stratification, adjusted D-dimer thresholds,special populations, isolated distal deep venous thrombosis, upper extremity deep venous thrombosis, outpatient treatment, and the new oral anticoagulants.
PMID: 26276907
ISSN: 1559-3908
CID: 3015452

Early recognition of acute thoracic aortic dissection and aneurysm

Leitman, I Michael; Suzuki, Kei; Wengrofsky, Aaron J; Menashe, Eyal; Poplawski, Michal; Woo, Kar-Mun; Geller, Charles M; Lucido, David; Bernik, Thomas; Zeifer, Barbara A; Patton, Byron
BACKGROUND:Thoracic aortic dissection (TAD) and aneurysm (TAA) are rare but catastrophic. Prompt recognition of TAD/TAA and differentiation from acute coronary syndrome (ACS) is difficult yet crucial. Earlier identification of TAA/TAD based upon routine emergency department screening is necessary. METHODS:A retrospective analysis of patients that presented with acute thoracic complaints to the ED from January 2007 through June 2012 was performed. Cases of TAA/TAD were compared to an equal number of controls which consisted of patients with the diagnosis of ACS. Demographics, physical findings, EKG, and the results of laboratory and radiological imaging were compared. P-value of > 0.05 was considered statistically significant. RESULTS:In total, 136 patients were identified with TAA/TAD, 0.36% of patients that presented with chest complaints. Compared to ACS patients, TAA/TAD group was older (68.9 vs. 63.2 years), less likely to be diabetic (13% vs 32%), less likely to complain of chest pain (47% vs 85%) and head and neck pain (4% vs 17%). The pain for the TAA/TAD group was less likely characterized as tight/heavy in nature (5% vs 37%). TAA/TAD patients were also less likely to experience shortness of breath (42% vs. 51%), palpitations (2% vs 9%) and dizziness (2% vs 13%) and had a greater incidence of focal lower extremity neurological deficits (6% vs 1%), bradycardia (15% vs. 5%) and tachypnea (53% vs. 22%). On multivariate analysis, increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction were independent predictors of ACS. CONCLUSIONS:Increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction can be used to differentiate acute coronary syndromes from thoracic aortic dissections/aneurysms.
PMCID:3874654
PMID: 24499618
ISSN: 1749-7922
CID: 3015442

Subtle vaginal evisceration resulting in small bowel evisceration: a case report [Case Report]

Woo, Kar-mun C; Linden, Judith A; Lowenstein, Robert A; Varghese, Jose C; Burch, Miguel A
BACKGROUND:Evisceration of bowel contents through the vagina is a rare event that may be complicated by bowel obstruction. OBJECTIVE:We report a case of vaginal evisceration with small bowel obstruction which, in contrast to previous, more dramatic case reports in the literature, is a more subtle and, in fact, characteristic clinical presentation for this unusual occurrence. CASE REPORT/METHODS:A 72-year-old woman with a previous history of pelvic surgery presented to the Emergency Department with lower abdominal discomfort and a prolapsing mass from her vagina. She was initially discharged home after bedside reduction of the mass, but returned 48 h later with worsening symptoms. A computed tomography scan on her repeat visit confirmed evisceration of bowel into the vaginal vault with obstruction of distal bowel loops. Surgical and gynecologic services were consulted and the patient underwent partial small bowel resection and vaginal cuff repair in the operating room. CONCLUSION/CONCLUSIONS:Early recognition of subtle presentations of vaginal evisceration is crucial for preserving bowel viability and preventing morbidity from bowel ischemia or infarction. Risk factors for this rare condition include postmenopausal status, previous pelvic surgery, and presence of an enterocele.
PMID: 21903354
ISSN: 0736-4679
CID: 3015432

High-risk chief complaints I: chest pain--the big three

Woo, Kar-mun C; Schneider, Jeffrey I
Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.
PMID: 19932401
ISSN: 1558-0539
CID: 3015422